FEATURES OF THE COURSE OF PREGNANCY AND CHILDBIRTH IN MULTIPLE PREGNANCIES

Relevance. Patients with multiple pregnancies are at high risk of perinatal complications.  Even with the modern development of medicine, perinatal mortality in twin pregnancies is 5 times higher than in singleton pregnancies, intrauterine fetal death is 4 times higher, neonatal – 6 times, perinatal – 10 times higher. The frequency of cerebral palsy in children with twins is 3–7 times higher, in triplets – 10 times. The level of antepartum and intrapartum complications from the mother is 2–10 times higher than that in patients with singleton pregnancies [1, р. 54].

Prematurity is considered as the main cause of neonatal mortality in multiple pregnancies. Premature labor is the leading cause of neonatal mortality and early and delayed disability. Preterm labor rates range from 6 to 12% in developed countries, and this figure is usually higher in developing countries. About 40% of all preterm labor occur before 34 weeks and 20% before 32 weeks. The contribution of these preterm  labor  to the overall perinatal morbidity and mortality is more than 50% [2, р. 123].

The course of multiple pregnancies is 3–7 times more complicated than single pregnancies. Syndrome of  growth retardation of one of the fetuses, the frequency of which is 10 times higher than in singleton pregnancies, and is 34% and 23% in monochorionic and dichorionic twins, respectively. The dependence on the type of placentation of the frequency of growth retardation in both fetuses is more pronounced: 7.5% for monochorionic and 1.7% for dichorionic twins [3, р. 125].

The relevance of the problem of multiple pregnancies lies in a significant number of complications during pregnancy and labor, an increase in the proportion of caesarean section, complications of the postpartum period, an increased level of antenatal losses at different gestational periods, and a high frequency of neurological disorders in surviving children [4, р. 126].

The aim of the study – was to study the features of the course of pregnancy and childbirth with multiple pregnancies.

Materials and methods. The analysis of the data of the histories of pregnancy and childbirth of 36 patients who were under observation with a diagnosis of multiple pregnancies was carried out.

Results of the study. Each woman had an extragenital pathology. The most common pathology of the kidneys and urinary tract (45.5%), of which the proportion of newly diagnosed pyelonephritis was 19.5%, chronic pyelonephritis in the stage of unstable remission and exacerbation 7.7%, cystitis 6% and asymptomatic bacteriuria 16.7% . Pregnant women with urinary tract pathology are at high risk of intrauterine infection and perinatal complications such as intrauterine fetal hypoxia and fetal growth retardation syndrome.

In second place are varicose veins of the lower extremities (23.7%), diseases of the gastrointestinal tract (17.7%), visual organs (14.2%), cardiovascular system (9.3%), diabetes mellitus (5.3%), thyroid hyperplasia (2.5%). During pregnancy, 22.5% of women suffered from respiratory infections.

According to the results of a study of complications of this pregnancy in the first trimester 14 (38.9%) pregnant women had signs of threatening early miscarriage. In the second trimester 11 (30.5%) pregnant women had a threat of late miscarriage and 7 (19.4%) pregnant women had mild anemia. The third trimester in 36 (100%) women examined was proceeding with complications: threatening premature labor, 8 (22.2%) pregnant women had moderate preeclampsia.

According to ultrasound in the first trimester 30 (83.3%) patients had dichorionic diamniotic twins and 6 (16.7%) patients had monochorionic diamniotic twins. The localization of the chorion is predominantly anterior in 24 pregnant women (66.7%), the posterior localization of the chorion is in 12 pregnant women (33.3%). The sizes of the yolk sacs were within normal limits in all patients. The average value of the coccygeal-parietal size of the fetuses was 58.2 ± 5.4 mm. The heart rate was 146 ± 4.2 beats / min. The length of the cervical canal was 41.4 ± 2.1 mm.

In the second trimester, an ultrasound examination was performed at a period of 19-20 weeks, the average size of the biparietal head size was 48±1.92 mm, abdominal circumference – 150±2.32 mm, head circumference – 172±4.25 mm. The average length of the femur was 31.4±1.22 mm, the leg bones – 29.6±1.14 mm, the humerus – 30.4±1.62 mm, the forearm bones – 29.3±1.44 mm. According to ultrasound in the second trimester 22 (61.1%) pregnant women had anterior localization of the placenta, 8 (22.2%) – posterior, and 6 (16.7%) – anterior and posterior. The maturity of the placenta was zero in all patients (100%). The amount of amniotic fluid is normal in 31 pregnant women (86.1%) and  in 5 pregnant women (13.9%) amniotic fluid with minor impurities. The average value of the amniotic fluid index was 12.4±0.5. The structural features of the umbilical cord were not identified; in all women the umbilical cord had 3 vessels.

In the third trimester, an ultrasound examination was performed at a period of 33-34 weeks, the average size of the biparietal head size was 84.9±2.4 mm, abdominal circumference – 289.3±3.4 mm, head circumference – 294.1±3,4 mm. The average length of the femur was 62.2±2.2 mm, the bones of the lower legs – 63.1±2.4 mm, the humerus – 61.1±2.4 mm, the bones of the forearm – 63.1±1.4 mm. The degree of maturity of the placenta in 15 pregnant women was 1 degree, in 21 pregnant women – 2-3 degrees. The amount of amniotic fluid is normal in 30 pregnant women (83.3%) and in 6 pregnant women (16.7%) moderate polyhydramnios. The mean value of the amniotic fluid index was 12.4±0.4.

Vaginal delivery was observed in 6 (16.7%) women, caesarean section – in 30 (83.3%) pregnant women. At 36-37 weeks, 28 patients (77.8%) were delivered, 6 (16.7%) by vaginal delivery and 22 (61.1%) by caesarean section, at 35 weeks 8 (22.2%) of the patient by cesarean section. In 42 (58.3%) newborns, 7-8 points were diagnosed, in 22 (30.6%) – 8-9 points, in 8 (11.1%) – 6-7 points. The outcome of labor was the birth of  72 children, with an average weight of 2500±250 grams and a height of 46±1.5 cm.

Conclusions. Analyzing the data obtained, it can be concluded that multiple pregnancy is a high-risk pregnancy that requires regular dynamic monitoring of both the health of the mother and the fetus. Multiple pregnancies place special, increased demands on the mother’s body. Delivery of a woman is recommended to be carried out in a high-level maternity hospital (perinatal center), which has powerful qualified neonatal resuscitation. The frequency of operative delivery in multiple pregnancies is significantly higher than in singleton pregnancies. However, the method of delivery depends on many factors and in each case, the tactics of labor management are developed individually.

1. National Vital Statistics Reports, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. – 2018. – Vol. 61. – № 1.
2. Maia S. Neto S. Preterm birth of twins // 21st European Congress of Obstetric and Gynaecology Antwerpen Belgium / 5 to 8 May 2016, 123.
3. Shtylla A., Kruja A., Kolici N. Fetal malformation in multiple pregnancies // 21st European Congress of Obstetric and Gynaecology Antwerpen- Belgium / 5 to 8 May 2016, 125.
4. Van Mieghem T, DeKoninck P, Eixarck E. Outcome prediction in monochorionic diamniotic twin pregnancies with moderately discordant amniotic fluid // 21st European Congress of Obstetric and Gynaecology Antwerpen Belgium / 5 to 8 May 2016, 126.

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